2019 PDP-Planner: Medicare Part D Donut Hole Calculator

Try one of our examples or your own scenerio ->Example 1 illustrates how the Donut Hole (Coverage Gap) works when the beneficiary only has monthly prescripiton (Rx) costs.Example 2 showns that if the same monthly costs are paid on a quarterly basis, the total retail costs do not change, however,
when one enters and leaves the Coverage Gap does changes.Example 3 shows an example of how to enter you medication costs if they are not consistent.

OR Enter your average prescription drug costs:*
This is the actual retail cost of your covered prescriptions.
Do not include non-covered prescriptions or non-prescription medications (ex: asprin or over-the-counter vitamins).

Paid Monthly:

Quarterly:

Semi-Annually:

Annually:

We will add all of these costs together to determine your total annual retail prescription costs.
Since we do not know when you are making these non-regular purchases, we will place these payments starting in month one (1).
You can find these values on your regular Medicare Part D plan statements or if you already know the annual costs,
just enter the value in the annual costs field.

Percentage of Generic vs. Brand drug purchases:*

Because of the donut hole discount, the percentage of generic vs. brand drug purchases will determine if and when you will exit the Coverage Gap.

Enter your plan's deductible:

$

The 2019 standard deductible is $415.

Choose the your coverage start month - usually January:*

Most plans start in January. If you are just turning 65 or a Medicaid recipient, your plan may start in a month other than January.

Enter your monthly premium:

$

You can enter your monthly premium, to have it calculated into the total.

* required

2019 Donut Hole Calculation Summary:

Summary of the annual retail cost of your drugs:

monthly retail: $0.00 x 12 = $0.00

quarterly retail: $2,400.00 x 4 = $9,600.00

semi-annual retail: $0.00 x 2 = $0.00

annual retail: $0.00 x 1 = $0.00

total retail of $9,600.00 to be used over 12 months of coverage

Percentage of Generic vs. Brand drug purchases used:

0% Generic / 100% Brand (not vaccine adjusted)

You will enter the Coverage Gap (Donut Hole):

in April

You will exit the Coverage Gap (Donut Hole):

in October

Your total annual Out-of-Pocket Costs without premium:

$2,116.63

2019 Donut Hole Calculation Details

Month

Plan Phase

Who Pays

TotalRetail

You

Plan

Mfgr

Gov

$$

1: Jan

Initial Coverage

$600.00

$1,800.00

$0.00

$0.00

$2,400.00

You are in the Initial Coverage Phase. Your costs so far $600.00.

$$

2: Feb

Initial Coverage

$0.00

$0.00

$0.00

$0.00

$2,400.00

You are in the Initial Coverage Phase. Your costs so far $600.00.

$$

3: Mar

Initial Coverage

$0.00

$0.00

$0.00

$0.00

$2,400.00

You are in the Initial Coverage Phase. Your costs so far $600.00.

$$

4: Apr

Initial Coverage

$355.00

$1,065.00

$0.00

$0.00

$3,820.00

You are in the Initial Coverage Phase. Your costs so far $955.00.

$$

4: Apr

Donut Hole

$245.00

$49.00

$686.00

$0.00

$4,800.00

You entered the Coverage Gap (Donut Hole) in April.Your costs so far including the 2019 Coverage Gap Discount are $1,200.00. Your credit toward exiting the Coverage Gap is $1,886.00. This includes what you spent plus what the brand-name drug manufacturer (Mfgr) spent on your behalf. For plan year 2019, Non-LIS Medicare Beneficiaries get a 63% discount on generics and a 75% discount on brand-name drugs purchased in the Coverage Gap. Read Q&A about the Discount...

$$

5: May

Donut Hole

$0.00

$0.00

$0.00

$0.00

$4,800.00

You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $1,200.00. Your credit toward exiting the Coverage Gap is $1,886.00.

$$

6: Jun

Donut Hole

$0.00

$0.00

$0.00

$0.00

$4,800.00

You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $1,200.00. Your credit toward exiting the Coverage Gap is $1,886.00.

$$

7: Jul

Donut Hole

$600.00

$120.00

$1,680.00

$0.00

$7,200.00

You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $1,800.00. Your credit toward exiting the Coverage Gap is $4,166.00.

$$

8: Aug

Donut Hole

$0.00

$0.00

$0.00

$0.00

$7,200.00

You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $1,800.00. Your credit toward exiting the Coverage Gap is $4,166.00.

$$

9: Sep

Donut Hole

$0.00

$0.00

$0.00

$0.00

$7,200.00

You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $1,800.00. Your credit toward exiting the Coverage Gap is $4,166.00.

$$

10: Oct

Donut Hole

$245.79

$49.16

$688.21

$0.00

$8,183.16

You are still in the Donut Hole. Your costs so far including the 2019 Coverage Gap Discount are $2,045.79. Your credit toward exiting the Coverage Gap is $5,100.00.

$

10: Oct

Catastrophic Coverage

$70.84

$212.53

$0.00

$1,133.47

$9,600.00

You exited the Coverage Gap (Donut Hole) in October and are now in the catastrophic coverage. We have used 5% to calculate your costs.
The actual calculation is $3.40 for generics, $8.5 for brands or 5% whichever is higher.Your costs so far $2,116.63.

$

11: Nov

Catastrophic Coverage

$0.00

$0.00

$0.00

$0.00

$9,600.00

You will remain in Catastrophic Coverage until the end of the year.Your costs so far $2,116.63.

$

12: Dec

Catastrophic Coverage

$0.00

$0.00

$0.00

$0.00

$9,600.00

You will remain in Catastrophic Coverage until the end of the year.Your costs so far $2,116.63.

Summary

Who Pays

TotalRetail

You

Plan

Mfgr

Gov

Totals without premium:

$2,116.63

$3,295.68

$3,054.21

$1,133.47

$9,600.00

Notes:* Co-payments do not influence when you will enter and leave the Donut Hole (which is based on plan’s negotiated retail drug costs). It will only affect your out-of-pocket costs.** For plan years 2011 and on, the chart values
include the Donut Hole Discount. Read Q&A about the Discount...

Legend:

$$$

You are responsible for 100% of your prescription (Rx) costs. This occurs during the Initial Deductible Phase of coverage. (Many plans do not have an initial deductible.) It also occured in the Coverage Gap (Donut Hole) unless your plan has Donut Hole coverage.

$$

You share your prescription (Rx) costs with your Medicare Part D plan provider. During the Initial Coverage Phase, you are responsible for 25% of your medication costs (basic or standard plans) or a co-payment on enhanced plans.

In plan year 2019, your drug costs are also shared during the Coverage Gap. The plan pays 63% of your generic drug costs and the drug manufacturer pays 75% of your brand drug costs. Read Q&A about the Discount...

$

You pay a small fraction of your prescription (Rx) costs. This occurs in Catastrophic Coverage. You pay 5% of your medication costs or $3.40 for generics or $8.5 for brand drugs (whichever is higher).

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This Q1Medicare.com Doughnut Hole calculator is based on the 2019 CMS Standard Benefit Medicare Part D plan and designed to estimate when a Medicare Part D beneficiary would (1) enter and exit the coverage gap and (2) the potential prescription costs for the year. The actual time when a Medicare Part D beneficiary enters the Doughnut Hole and the costs associated with the plan may vary depending on the chosen Medicare Part D plan.

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